The present invention relates generally to an information collection and processing system and an automated method for collecting and processing information. More particularly, the present invention relates to an information collection and processing system and automated method for use by an alliance of organizations providing managed and non-managed health care to a given population.
The advent of managed care in the health care industry has brought substantial changes to the ways participants in the industry deal with each other. These changes are especially apparent in the areas of financial risk and accountability. Through creation of health insurance products based on patient volume, and specific provider networks, insurors have shifted financial risk to physicians, hospitals and other health care service organizations. These changes have occurred while most of the data and administrative tools required to understand and manage such risk have remained with insurors.
In responding to changing industry conditions, physicians, hospitals, and other health care services organizations have formed economic alliances (an “EA”) to provide managed and non-managed health care to a given population or geographic area. An EA contracts with multiple insurors to provide managed and non-managed health care to a population under varied reimbursement arrangements, medical practice guidelines, and health plan process requirements. A need exists for automated systems and methods to manage the complex and numerous variables associated with the various arrangements, guidelines, and requirements with which an EA must contend on a day-to-day basis.
It is an object of the present invention to provide automated systems and methods for use by an economic alliance of health care providers and service organizations rendering health care services and providing health care products to a given population.
Another object of the present invention is to provide automated systems and methods for assisting an economic alliance of health care organizations in the management of financial risk inherent in the health care industry.
Yet another object of the present invention is to provide automated systems and methods which allow an economic alliance of health care organizations, as well as individual organizations within the alliance, to more efficiently and effectively deliver health care goods and services under varying reimbursement arrangements, practice guidelines and health plan requirements.
These and other objects are met by an information collection and processing system which comprises an information storage arrangement, a processor for reading and writing information from and to the storage arrangement and for processing such information, and input and output devices for communicating information to and from the processor and the storage arrangement. The information storage arrangement comprises several elements or portions, including a first portion for storing information relating to a plurality of contractual relationships existing between the economic alliance, a plurality of providers of goods and/or services, and a plurality of payors. A second portion of the storage arrangement holds information relating to a plurality of patients in a given population. A third portion of the storage arrangement holds information relating to utilization management functions, demand management functions, catastrophic case management functions, or chronic and preventive services management functions. A fourth portion of the storage arrangement holds information relating to transactions between the alliance, the providers and the payors.
In a preferred embodiment of the invention, information relating to contractual relationships is scanned or imaged into the system. This process may include assigning a unique identifier to elements of information stored in the first portion of the storage arrangement. The unique identifiers are preferably stored in a data base referred to as a provider information management system (“PIMS”) data base.
In one embodiment of the invention, the storage arrangement further comprises means for identifying the plurality of providers, payors, or patients by any of a plurality of identifiers by which said providers, payors or patients may be known. This means comprises that portion of the storage arrangement in which a plurality of known identifiers for each of the plurality of providers, payors, or patients are stored.
A preferred embodiment of the invention may also include a capitation data base for storing information relating to capitation contracts, and a rules data base for storing rules relating to system utilization, billing and benefits. An automated letter generating system may also be provided for producing application packages relating to certification or credentialing processes for a provider using information stored in a demographic data base. Computer means for monitoring expiration dates of applicable certification or credentialing information, and for automatically generating a request for updated information, may also be provided.
The storage arrangement may also include means for storing information relating to patient contacts with the alliance, or with one of the plurality of providers in the alliance, in a quality assurance management module of a total managed care system (“TMCS”) data base.
In one embodiment of the invention, the information relating to utilization management functions stored in the third portion of the storage arrangement includes information relating to preauthorizations, referral management, and protocol management. The information in the storage arrangement may comprise information relating to claims and encounters, authorizations, health risk assessments and reminder status. This information may be processed to determine a need for generating a case management referral, a disease management referral or an education referral. The system may further comprise means for providing to the providers online access to the generated referrals. This online access may comprise a graphical user interface screen. In addition to referrals, the system of the present invention may also provide means for creating a summary of all patient contacts with the alliance and providers and for providing online access to this summary. This provides the capability of obtaining a quick, complete summary of all contacts a particular patient may have had with the alliance or the providers (or the payors) in a given period of time.
One embodiment of the invention may further comprise means for identifying, within the given population, subpopulations requiring health care information and/or reminders, and means for causing the information and/or reminders to be forwarded to those patients to improve compliance with preventive and disease specific protocols. Information relating to the identification and notification of the subpopulations may be stored in medical management data repository of the TMCS data base.
One embodiment of the invention may further comprise program means for storing information relating to accounts receivables, means for comparing remittances received to amounts expected to be received for respective receivables, and means for initiating a first action if the remittance falls within established tolerances, for example, a predetermined percentage of the respective receivable, and means for initiating a second action if the remittance falls outside of the predetermined percentage of the respective receivable. For instances in which a portion of the population is covered by a capitation agreement, automated means for processing claims relating to transactions covered by the capitation agreement may also be provided. The system may further include means for periodically generating capitation accounts receivables for transactions covered by the capitation agreement, means for comparing respective capitation payments to the accounts receivables, and means for initiating an action if the capitation payments do not fall within a predetermined percentage of the capitation accounts receivables.
The present invention further includes an automated method for use by an alliance of organizations providing managed and non-managed health care to a given population. The automated method comprises the steps of:                a. storing information relating to a plurality of contractual relationships existing between the alliance, a plurality of providers of goods and/or services, and a plurality of payors;        b. storing information, including a patient identifier, relating to a plurality of patients in the given population, and a record of encounters between each patient and each provider;        c. storing information relating to transactions between the alliance, the providers and the payors;        d. storing a plurality of identifiers for each of the plurality of providers and payors; and        e. processing the stored information to associate information relating to a particular patient with the patient's identifier, and to associate information relating to a particular provider or payor with each stored identifier for that provider or payor.        
In one embodiment of the inventive method, the step of storing information relating to contractual relationships includes storing information relating to such relationships existing between the alliance and a plurality of providers of goods and/or services, the alliance and the plurality of payors, the plurality of providers, and the plurality of providers and the payors. The subject method may also include the steps of assigning a unique identifier to elements of information relating to the contractual relationships, and storing the unique identifiers in the PIMS data base. One embodiment of the invention may also include one or more of the additional steps of:
storing demographic information relating to the alliance, the providers, and the payors in a demographics data base; storing information relating to capitation contracts in a capitation data base; and storing rules relating to system utilization, billing and benefits in a rules data base. The additional step of generating an application package relating to certification or credentialing of a provider using information stored in the demographics data base may also be provided. The method of the present invention may also include the additional steps of monitoring expiration dates of applicable certification or credentialing information, and automatically generating a request for updated information.
In one embodiment of the method of the present invention, the information relating to a plurality of patients comprises rosters obtained from each of the plurality of providers. The invention may also include the additional steps of comparing patient names from the plurality of rosters, and eliminating duplicate names to create a patient master file. The step of storing additional information, including demographic information and health risk assessment data, associated with individual patients in the patient master file to create a customer enrollment system data base may also be included. One embodiment of the invention includes the additional step of storing patient specific rules in a patient rules data base.
One embodiment of the method of the present invention includes the additional steps of storing information relating to communications received from or sent to a patient in the patient master file and in a “tracking” data base which may be part of an activity management system. The method may also include the additional steps of inputting information relating to new patients into the patient master file, and updating the activity management system regarding communications sent to or received from the new patients. The invention may also include the step of allowing providers real time access to information relating to a patient in the patient master file for determination of eligibility status at the time services are provided. Patient rosters from the plurality of providers may be inputted periodically and compared to eliminate duplication and create an updated patient master file.
One embodiment of the method of the present invention includes the step of storing information relating to at least one of utilization management functions, demand management functions, catastrophic case management functions, and chronic and preventive services management functions. Utilization management functions may include preauthorizations, referral management, and protocol management.
An embodiment of the invention may include authorizing referral care, in accordance with information contained in the rules data base, and notifying a referral provider of the referral authorization. In this embodiment, the referral provider may be provided with access to the rules data base.
One embodiment of the method of the present invention may include the additional steps of identifying, within the given population, subpopulations requiring health care information and/or reminders, and causing the information and/or reminders to be forwarded to patients to improve compliance with preventive and disease specific protocols. The subject method may also include the steps of storing information relating to the identification of the subpopulations in a tracking data base. The additional steps of identifying at least one indicator of a potentially high dollar case, and creating a case management record relating to a course of treatment for such case, may also be provided.
One embodiment of the method of the present invention comprises the additional steps of storing information relating to accounts receivables, comparing remittances received to amounts expected to be received for respective receivables, initiating a first action if the remittance falls within predetermined limits of the respective receivable, and initiating a second action if the remittance falls outside of predetermined limits of the respective receivable.
In one embodiment of the invention, at least a portion of the population is covered by a capitation agreement. This embodiment of the present invention may include the additional steps of automatically processing claims relating to transactions covered by the capitation agreement, periodically generating capitation accounts receivables for transactions covered by the capitation agreement, comparing respective capitation payments to the accounts receivables, and initiating an action if the capitation payments do not fall within a predetermined percentage of the capitation accounts receivables.
Other goals, advantages and novel features of the present invention will become apparent from the following detailed description of the invention when considered in conjunction with the accompanying drawings.